CMS Price Transparency Data

Office visit, established patient (20-29 min)

Facility: Sanford Sheldon Medical Center

Billing Code: 99213 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 99213
Insurance Median: $99
Cash Discount Price: $123
vs. Medicare Baseline: 1.04x Medicare

The contracted insurance negotiated median rate for a Office visit, established patient (20-29 min) at Sanford Sheldon Medical Center is $99. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $123. Compared to the federal Medicare reimbursement reference rate of $95.19, this hospital’s rate is 1.04x the Medicare baseline. Located in 118 North Seventh Avenue, Po Box 250, Sheldon, IA.

Cash / Self-Pay

$123

Average discount available for prompt cash payment at this facility.

Insurance Median

$99

Median negotiated contract rate across all mapped commercial carriers.

Medicare Reference Rate

$95.19

Standard federal government reimbursement rate for this code.

Visual Cost Comparison vs. Medicare

Medicare Reference Baseline: $95.19 (100%)

Cash / Self-Pay: $123 (129%)

Insurance Median: $99 (104%)

Cash: $123 (129% of Medicare)

Ins. Median: $99 (104% of Medicare)

Understanding this gauge: We use the federal Medicare rate of $95.19 as the cost baseline. Rates below the baseline represent excellent value. In-network commercial rates commonly hover around 150% - 250% of Medicare, while rates exceeding 300% are elevated. Hover over the green and blue markers to view detailed calculations.

Out-of-Pocket Cost Estimator

Estimate whether it is more economical to use your insurance or pay the upfront self-pay cash rate.

Billing Status

Remaining Deductible ($)

Your Coinsurance Rate (%)

Input your details and click calculate to compare out-of-pocket costs.

Commercial Insurance Negotiated Rates

Negotiated contract ranges established by major commercial carriers at this facility.

Carrier / Plan Group	Contract Rate Range	vs. Medicare Reference
Sanford Health Plan Align	$44	46%
Ucare	$47 - $135	49%
Aetna	$48 - $134	50%
Blue Cross Blue Shield	$48	50%
Health Partners	$48 - $116	50%
Medicare (plans)	$48	50%
UnitedHealthcare	$48 - $129	50%
Primewest	$49	51%
Wellmark	$77 - $80	81%
Sanford Health Plan	$83 - $97	87%
Security Health Plan	$85	89%
Medica	$127 - $136	133%
First Choice Health Network	$139	146%
Healthez	$139	146%
Multiplan	$139	146%

Self-Pay Upfront Cash Action Plan

Request a "Self-Pay classification" with the billing desk before receiving care.
Ask for a written "Prompt-Pay Discount" agreement quoting the price of $123.
Request and sign a "Waiver of Insurance Submission" to prevent automatic billing.
Verify CPT Code matches exactly: 99213.

Insurance In-Network Protection Plan

Contact your insurance company to confirm Sanford Sheldon Medical Center is fully in-network.
Ask your insurer if "Prior Authorization" is required for CPT code 99213.
Confirm the specific physician or imaging center is also in-network (not just the hospital building).
Audit your Explanation of Benefits (EOB) against the final itemized hospital invoice.